Attachment_2_USAID_DBA_Application.doc

Form-1 Application for Defense Base Act Insurance eMail: usaiddbains@aon.com

Single Source Contract

# AID-OAA-C-10-00027

( Business Information (headquarters)

( Insurance Brokers & other third parties

Applicant/Insured/ (as stated in your

Complete this section to authorize another third party such as a broker, agent, or consultant to be copied on our direct communications to you. Third parties will not be copied if this section is blank.

USAID Contract)

Company Name & dba:

Contact Name & Title:

Address:

City, State, Zip Code, Country:

Telephone:

Fax:

E.mail Address:

Indicate your Organization’s Structure:

FORMCHECKBOX

Corporation

FORMCHECKBOX

Joint Venture

FORMCHECKBOX

Partnership

FORMCHECKBOX

Sole Proprietor

FORMCHECKBOX

S-Corporation

FORMCHECKBOX

Other_

FORMCHECKBOX

Independent Consultant / Contractor

Date Contract Awarded:

Scope of Work:

Proposed Contract Price $:

Applicant is a Prime or Sub-contractor:

Overseas Start Date:

If this is a policy renewal, please provide renewal date

Policy will be effective for 12 months from start date or date application received, which ever is later. If you need space to report additional contracts, please list them on a separate sheet. Fill in “see attached” in the contract number space above.

C. Exposure / Premium Calculation

Remuneration Employee Information – Indicate Annual remuneration as defined below.

For the purposes of this contract, Employee Remuneration is defined as salary plus overseas recruitment incentives, post differential and danger pay, but excludes per diem, housing allowance, travel expenses, temporary quarters allowance, education allowance, and other miscellaneous post allowances. Final remuneration will be adjusted at annual final audit.

1.Type of Contract

(Services, Construction, or Security Guards)

Third Country National (TCN) Remuneration Cooperating Country National (CCN) Local Nationals (LN)

Services - $2.00

Construction - $4.50

Security - $7.50

3. Estimated Total Premium

Notes:

1.

If more than one category of work is to be performed, this should be pro-rated among all applicable categories. Clerical stays with category.

2.

Any US Citizens or legal resident of the United States or any person hired in the United States.

3.

Note: No Minimum, Subject to final audit at end of annual policy period – additional task orders will be included in the same policy and remuneration audited.

Form-1 eMail: usaiddbains@aon.com

Single Source Contract

# AID-OAA-C-10-00027

D. Country Locations/Job Sites

Policy Instructions:

Once completed, email to Aon USAID eMail: usaiddbains@aon.com Aon will review same day and accept if complete and verify coverage has been bound within 24 hours.

Fred Robinson

Primary Administrator

Support & Policy Servicing

(o) 415-486-7516, (f) 415-486-7059

Fred.Robinson@aon.com Back-up

Angela Falcone

(o) 415-486-7000

Program Administrator

(o) 202-862-5306, (f) 202-429-8530

Ellen.Rowan@aon.com Back-up

Chris Thompson

(o) 202-862-5302 Verification of coverage – certificate LS241 will be provided with acceptance with Aon invoice for immediate payment.

Payment due immediately. If payment is not received within 10 days of receipt of invoice, policy will be canceled flat.

“Contracting Officer to obtain (and file) a copy of DBA coverage from each USAID contractor for which contract performance is to occur outside of the U.S. This is to be obtained before any overseas work begins.

E. Signature Block : I verify the information presented above and attachments are correct and submit application for coverage to be bound:

Applicant: / Insured / Company

(please print)

At the end of the policy period the insured, will be provided final audit computation worksheet and adjustment of premium will be processed.

Form-1

USAID DBA WAIVER LIST

eMail: usaiddbains@aon.com

Single Source Contract

# AID-OAA-C-10-00027

Waivers are quite old and many are outdated. Economies and political changes have occurred in many countries which impact the viability of Workers Compensation programs overseas and delivery of such benefits. Consequently, contractors (and subcontractors) are required to determine the existence of valid Workers Compensation programs in those foreign countries in which work is to be performed under a U.S. Government contract. This is mandatory before reliance on any of the country waivers listed.

Albania

Antigua

Armenia

Azerbaijan

Bahamas

Bangladesh

Barbados

Belarus

Belize

Benin

Bolivia

Bosnia & Herzegovina

Botswana

Brazil

Bulgaria

Burkina Faso

Burundi

Cambodia

Cameroon

Cape Verde

Chad

Chile

Colombia

Costa Rica

Cote d’Ivoire

Croatia

Czech Republic

Democratic Republic of the Congo Montenegro

Djibouti

Dominica

Dominican Republic

Ecuador

Egypt

El Salvador

Equatorial Guinea

Estonia

Ethiopia

Fiji

Gambia

Georgia

Ghana

Grenada

Guatemala

Guinea

Guinea-Bissau

Haiti

Honduras

Hungary

India

Indonesia

Israel

Italy

Jamaica

Jordan

Kazakhstan

Kenya

Korea

Krygyzstan

Latvia

Lebanon

Lesotho

Liberia

Lithuania

Macedonia

Madagascar

Malawi

Mali

Mauritania

Mauritius

Mexico

Moldova

Mongolia

Morocco

Mozambique

Namibia

Nepal

New Caledonia

Nicaragua

Niger

Nigeria

Oman

Pakistan

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Poland

Portugal

Russian Federation

Rwanda St. Christopher and Nevis St. Lucia St. Vincent Senegal Serbia Seychelles Sierra Leone Slovak Republic Slovenia

Somalia South Africa Sri Lanka Sudan Swaziland Syria Tajikistan Tanzania Thailand Togo Tonga Tunisia Turkey Turkmenistan Uganda Ukraine Uruguay

Uzbekistan Vietnam Western Samoa Yemen Yugoslavia Zambia Zimbabwe

USAID – Application 11-15-10 Edition